Micromedex在加護病房藥師在加護病房藥師在加護病房藥師在加護病房藥師工作與教學之應用工作與教學之應用工作與教學之應用工作與教學之應用

姚淑惠 資深藥師

中國醫藥大學附設醫院 藥劑部

2012 07 12 11:20~12:10

Outline

� 教學目標

1.讓學員學會如何從micromedex找到實用資料

2.讓學員學會如何引導藥學生查詢micromedex與應用藥物資訊

� 綱要說明

1.以Micromedex為首選參考資料庫的優點

2.查Micromedex對加護病房藥師的方便性與參考價值以外科與兒科為例

3.如何以臨床問題引導學生查資料及給予教學回饋

1.

以Micromedex為

首選參考資料庫的優點

快速與方便

藥物資料庫藥物資料庫藥物資料庫藥物資料庫

� 一級資料庫

� Trial report

(original paper)

� 二級資料庫

� MicroMedex

� Medline, PubMed

� UptoDate

� 三級資料庫

� Textbook

� 時效性

� 一(新)＞二＞三(舊)

� 完整性

� 三＞二＞一(少)

�依據問題選擇最依據問題選擇最依據問題選擇最依據問題選擇最適合的資料庫適合的資料庫適合的資料庫適合的資料庫

藥物資料庫藥物資料庫藥物資料庫藥物資料庫之分級及各級特性之分級及各級特性之分級及各級特性之分級及各級特性分級 三級資料庫

Tertiary Resources

二級資料庫

Secondary Resources

一級資料庫

Primary Resources

內容 教科書

回顧性文章(review articles)

網路上或資料庫的一般性資料

提供一級文獻的目錄或摘要

Medline

Up to date

MicroMedex

研究報告

controlled trials

cohort studies

case series or reports

優點 大部份的資料都找得到

對題材提供簡要及全面的介紹

使用便利、容易、較為人熟悉

可協助快速尋找所需的一級文獻 資料最新

說明深入

可親自評估研究的可用性

缺點 1. 資料不夠新

2. 資料不夠深入完整，原因包括

編幅受限

作者搜尋的資料不全

3. 資料錯誤，包括

轉錄或翻譯錯誤

作者偏見或專業性不足

1. 要學會使用適當的關鍵字及搜尋方式

2. 不同二級資源的使用方式會有所不同

1. 需要有評估一級文獻之能力

2. 單一研究的結果不夠全面，要閱讀及評估大量文獻則需花不少時間

時效性：1(新)＞2＞3(舊) 完整性：3＞2＞1(少)

e-book Update有時候也很快!

Micromedex Home page

Five tools available in the

Micromedex 2.0

• Drug Interactions - allows you to check for interacting drug ingredients, their

effects, and their clinical significance. Interaction information can be calculated for a

single drug or between multiple drugs.

• Trissel’s™ 2 IV Compatibility - provides easy access to proven Trissel’s 2 data to

assist with accurate IV compatibility decisions

• Drug Identification - finds drugs based on their imprint code or physical

description

• Tox & Drug Product Lookup - to find product, manufacturer contact, and related

toxicologic management information on: drugs, commercial/household products

and chemicals, plants and animals, and slang terms/street names for drugs or

substances

• Drug Comparison - provides a side-by-side drug information comparison

• Calculators - includes: antidote and dosing calculators and nomograms, lab values,

dosing tools, clinical calculators, and measurement calculators.

以藥名以藥名以藥名以藥名 病名或病名或病名或病名或 症狀搜尋症狀搜尋症狀搜尋症狀搜尋

藥物綜述資訊

檢視詳細文件

DrugPoint (summary)

� Dose & Indications

� 肝、腎不全劑量調整

� 其它疾病劑量調整

� Contraindications/Warning

� Do Not Confuse, …….

� Drug Interactions(single)

� Adverse Effects

� IV compatibility

� Name info

� Mechanism of action/Pharmacokinetics

� Administration/Monitoring

� How Supplied

� Toxicology

� Clinical teaching

� References

DrugDex

IV 相容性相容性相容性相容性 在搜尋欄位鍵入藥物名稱在搜尋欄位鍵入藥物名稱在搜尋欄位鍵入藥物名稱在搜尋欄位鍵入藥物名稱（（（（品牌品牌品牌品牌或學名藥或學名藥或學名藥或學名藥））））選擇藥物並按一下選擇藥物並按一下選擇藥物並按一下選擇藥物並按一下（（（（新增新增新增新增））））按鈕按鈕按鈕按鈕

� Y-site

� Admixture

Drug 1

Drug 2

Drug 1+ Drug 2

IV compatibility

Drug 1 Drug 2

藥名、濃度、廠商名稱

相容性

物理、化學相容性貯藏資訊

參考文獻、容器資訊研究時間、方法

Drug interactions

Drug-Drug

Drug-Lactation

Drug-Pregnancy

2.

查Micromedex對加護病房藥師的方便性與參考價值

以兒科與外科為例

快速入門與資料參考性高

Optimal Medication Therapy

� Meeting Patients’ Needs in an Evolving Health Care System--Critical care

� Optimal medication therapy results

- safety

- effective

- efficient

- culturally sensitive medication ordering

- order fulfillment, administration, and monitoring

� which achieves desired clinical outcomes for a specific patient

American College of Clinical Pharmacy Commentary

(Pharmacotherapy 2010;30(11):350e–359e)

The process should be influenced by

� best evidence/practices

� based on knowledge of pathophysiology,

pharmacology (including pharmacokinetics and

pharmacodynamics), pharmacotherapy, other

therapeutic modalities, pharmacogenomics,

pharmacoeconomics, quality-of-life issues,

� principles of patient safety, and ethical/legal

considerations

Medication therapy plans

查房前準備工作查房前準備工作查房前準備工作查房前準備工作 –––– 使用藥物使用藥物使用藥物使用藥物

查詢與確認每一項藥品每一項藥品每一項藥品每一項藥品, 以確認符合下列查核事項:

� 適應症、劑量、途徑、頻次….

� 過敏史

� 疾病現況與用藥是否相符合

� 是否出現藥物過敏或不良反應與監測參數

� 是否有重複用藥

� 是否有藥物交互作用

� 給藥方式是否恰當

� ……

從電子病歷中查詢病患資料從電子病歷中查詢病患資料從電子病歷中查詢病患資料從電子病歷中查詢病患資料

1. 用藥記錄用藥記錄用藥記錄用藥記錄(medication profile)

- 記錄在何處記錄在何處記錄在何處記錄在何處

- 藥物使用狀況藥物使用狀況藥物使用狀況藥物使用狀況

2. 使用藥物之適應症使用藥物之適應症使用藥物之適應症使用藥物之適應症

- 使用適應症使用適應症使用適應症使用適應症

- 使用於何種臨床症狀使用於何種臨床症狀使用於何種臨床症狀使用於何種臨床症狀(symptom and/or sign)

3. 病患用藥物相關檢驗數據病患用藥物相關檢驗數據病患用藥物相關檢驗數據病患用藥物相關檢驗數據

- 藥物治療成效藥物治療成效藥物治療成效藥物治療成效

- 藥物副作用或毒性反應藥物副作用或毒性反應藥物副作用或毒性反應藥物副作用或毒性反應

4. 實證醫學參考資料實證醫學參考資料實證醫學參考資料實證醫學參考資料

- 查詢藥物使用是否依據實證或建議準則查詢藥物使用是否依據實證或建議準則查詢藥物使用是否依據實證或建議準則查詢藥物使用是否依據實證或建議準則

查詢病人用藥查詢病人用藥查詢病人用藥查詢病人用藥資訊資訊資訊資訊----1111

查詢病人用藥資訊查詢病人用藥資訊查詢病人用藥資訊查詢病人用藥資訊----2222

Component of a FARM Note and a SOAP Note

PWDT FARM Note SOAP Note

Findings The identified or suggestive patient-specific information

that gives a basis for or leads to the recognition of a

pharmacotherapy problem or indication for pharmacist

intervention

Findings (F)

Subjective and Objective data

incorporate into same section

Subjective data (S)

Separated from

Objective data (O)

Desired outcomes Assessment (A)

The pharmacist’s clinical judgment based on his or her

findings-thus it is no better than the database(the

findings); the assessment forms the basis for the

intervention plan

Desired endpoints

Drug-related problems

Therapeutic selection Resolutions/Recommendation (R) Plan (P)

Monitoring parameters Monitoring (M)

Follow-up

PWDT: pharmacist’s workup of drug therapy

Ref: Comprehensive Pharmacy Review 7th edition

p467 table 20-2 Lippincott Williams &Wilkins

2010

PICU case

phytonadione dosage and route

8 months old male infant admmitted from ER to PICU due to

1. Acute hepatic failure

2. Failure to thrive

3. Volume depletion

4. Jaundice

Underline problems:

(1).VLBW preterm infant, GA 28wks, BW 1060gm, NSD, A/S 8->9

(2).Respiratory distress syndrome Gr III s/p Survanta x 1 dose

(3).Fetal and neonatal intraventricular hemorrhage IVH III

(4).ileal perforation s/p ileostomy (8/29) and revision (10/26)

(5).posthemorrhagic hydrocephalus s/p EVD then s/p VP shunt

(6).PDA s/p ibuprofen x 4 doses and PDA ligation

(7).bacterial meningitis (K.P and MDRAB)

(8).Bronchopulmonary dysplasia

(9).Stage III ROP with plus disease s/p operation

phytonadione

Pediatric dose of phytonadione

SICU case

Amphotericin dosage

56 Y/O female 165/64.9kg, liver transplant in 廣州 under immunosuppresion agent use. Surgical wound infection s/p wound debridement.

Laboratory data: wbc 14.46, Hb 7.4, platelet 546, Creatinine2.15, GFR 25, K3.3, bilT/D 3.29/1.89, Tacrolimus drug level 6.3

Doctor want to know the dosage regimen for her ?

Amphotericin B

DrugPoint and/or DrugDex

Adult doseing

Different options for user

Tox & Drug Product Lookup

Evidence summary of original article

3.

如何以臨床問題引導學生查資料及給予教學回饋

延伸繼有知識及強化學習者的查閱及判讀能力

ADR- Skin Rash

報告藥師：林oo 藥師

指導藥師：姚淑惠 藥師

報告日期：101年03月01日

Problem list

� 檢視現行用藥中，何者藥物可能會產生1/30

Skin rash on torso?

O:1/28 1/29 1/30 1/31 2/1 2/2 2/3

MoxiFloxacin(針劑)

400mg/250ml/BT400mg QD

OMEPRAZOLE (F) Inj 40mg/VI 40mg QD

Ranitidine 50mg/2ml/Amp50mg q8h

KCL 10meq

in 0.33% G/S 500ml/Bag3BT QD

Metoclopramide 10mg/2cc/Am 10mg q12h

Ultracet Tab (複方) 1# QID

Mosapride 5mg/T 5mg TID

A：：：：

� Which drugs could be the cause of skin rash?

� Candidate: Moxifloxacin or Omeprazole

P：Sugg. DC of Moxifloxacin & Omeprazole

F/u skin rash condition

Moxifloxacin –induced skin

rash � Incidence: oral/IV, 0.1% to less than 2%

� Some of the adverse events were due to

hypersensitivity and usually occurred after

the administration of multiple doses.

� Discontinue moxifloxacin hydrochloride if a

patient experiences rash or if any

hypersensitivity reaction is suspected and

initiate appropriate supportive measures

Omprazole –induced skin rash

1) Incidence: 1.5%[181]2) In worldwide clinical trials (n=3096), rash

was reported in 1.5% of omeprazole-treated

patients [181].

3) In a study of 104 assessable patients, only

1 patient reported an adverse drug reaction

which was a rash. This study was evaluating the efficacy of omeprazole for treating

gastroesophageal reflux disease in intellectually disabled patients

Metoclopramide - Rash

� In postmarketing experience, a few cases of rash and urticaria have been reported with

the use of metoclopramide tablets. A causal

relationship to drug exposure has not been

established .

� Metoclopramide has occasionally been

reported to cause urticaria or maculopapular

rashes.

Chronic Heart Failure

in a 44 year-old female with

HTN And DM

報告藥師：林 o o

指導藥師：姚淑惠 林玟玲

Medication Therapy - 2

� NITROGLYCERIN(新劑型新劑型新劑型新劑型) 5mg/10ml/Amp

� 可原液輸注或以NS, D5W或LR，稀釋至0.05-0.5 mg/ml。

� 此藥會被polyvinyl chloride吸附(15-80%不等)，建議使用玻璃，聚乙烯(polyethylene)或聚丙烯(polypropylene)製成的容器盛裝藥物。

� Peripheral and coronary venous and arterial vasodilation resulting in decreased preload and afterload and increased coronary blood flow, thus increasing myocardial oxygen supply and decreasing myocardial oxygen demand. Clinical investigation has also suggested that organic nitrates interrupt platelet hyperactivity.

� 0.6cc/hr = (0.6cc*5mg/10ml)/60 mg/min = 0.005mg/min

= 5µg/ml – CHF initial dose

MicroMedex®

Ultract (Actainophen + Tramadol) - Rash

� Rash� 1) Incidence: 1% or greater

� 2) Rash was reported in at least 1% of patients receiving tramadol/acetaminophen in single-dose or repeated-dose clinical studies

� Pruritus� 1) Incidence: 1% to 2%

� 2) Pruritus occurred in 2% of patients receiving tramadol/acetaminophen for 5 days (average of at least 6 tablets/day) in clinical trials (n=142) .

� 3) Pruritus was reported in at least 1% of patients receiving tramadol/acetaminophen in single-dose or repeated-dose clinical studies.

� Stevens-Johnson syndrome� 1) Stevens-Johnson syndrome has been reported in patients

receiving tramadol in clinical trials .

Case Report

A 45years old male with NSTEMI,

hypertension and Type II Diabetes Mellitus

報告藥師：王 o o

指導藥師：姚淑惠林玟玲

Presentation outlines

� Patient general information- Basic data

- Chief complaint

- Past and Other history

- Physical Examination

- Lab. data

- Images

- Diagnosis

� Medication Therapy

� Disease review – NSTEMI(Non ST elevated

myocardial infarction)

� SOAP note of drug evaluation

Medication Therapy-ER

藥品名藥品名藥品名藥品名 劑量劑量劑量劑量 頻率頻率頻率頻率 途徑途徑途徑途徑 用法用法用法用法

Heparin 25000u/5ml/VI** 0.2vial stat Iv Loading 50cc/hr(2500u)

Heparin 25000u/5ml/VI** 1vial stat Iv 16cc/hr(800u)

ASPirin 300mg/T 1# stat po 外院外院外院外院 100mg

Clopidogrel 75mg/T 4# stat po 外院外院外院外院 300mg

Reference� 2011ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007

Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;57:1920–59.

� http://www.vghks.gov.tw/icu/doc09.htm

� J Am Coll Cardiol. 2011 May 10;57（19）:e215-367.

� 2010 高血壓治療指引 http://www.tsoc.org.tw/db/Jour/2/20101231/14.pdf

� MICRMEDEX

� PHARMACOTHERAPY

� UP TO DATE

� Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK;

Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial

Investigators. Effects of clopidogrel in addition to aspirin in patients

with acute coronary syndromes without ST-segment elevation. N Engl

J Med 2001;345:494-502.

Micromedex 2:

A fast track for drug information search

Knowledge of pharmacotherapy groundwork

Table 2. Recommendations for Early Hospital Care Antiplatelet Therapy

The End

Thank you